Provider Demographics
NPI:1881830370
Name:KIMBROUGH, COLLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:COLLIS
Middle Name:
Last Name:KIMBROUGH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1662
Mailing Address - Country:US
Mailing Address - Phone:954-561-3112
Mailing Address - Fax:
Practice Address - Street 1:2655 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1662
Practice Address - Country:US
Practice Address - Phone:954-561-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 91901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical